Native American Business APPLICATION FOR CERTIFICATION

Transcription

1 Confederated Tribes of the Grand Ronde Tribal Employment Rights Office Native American Business APPLICATION FOR CERTIFICATION This application is for certification of a majority or wholly- owned Grand Ronde Tribal owned or Native American owned business interested in providing their services and/or products via contracting opportunities under the Tribal Employment Rights Ordinance, Resolution and as provided for by the Indian Self- Determination and Education Assistance Act (P.L ), specifically 7(b), and other applicable federal and tribal laws. Certification of majority or wholly- owned Grand Ronde Tribal owned or Native American owned business is designed to: 1) Verify that the applicant is a Grand Ronde Tribal member or an enrolled member of a federally recognized American Indian tribe; 2) That the applicant is majority owner, if not 100%, of the business, and; 3) That the applicant is the primary beneficiary of the business being certified. Documentation and information required is essential to fulfill the criteria. Any deliberate or intentional effort to misrepresent the ownership of the business applying for certification will result in exclusion of contract opportunities by the Grand Ronde TERO program. Submit the certification application to: Tribal Employment Rights Program Confederated Tribes of the Grand Ronde 9615 Grand Ronde Road, Grand Ronde, OR Fax: (503) Please call (503) if you have questions or need more information. documentation requested. Please submit all

2 Grand Ronde Tribal Employment Rights Office APPLICATION FOR CERTIFICATION Name of firm: Corporation name (if applicable): Name of Principal Owner: Business Address: City: State: Zip: County: Business Ph: Fax No: or Web Address: Owners Full Name: Residential Address of Owner: City: County: State: Zip: Tribal Affiliation: Tribal Enrollment No: _ A copy of Tribal ID is required to process application Social Security # Summary of Business Type of Business: [ ] Construction [ ] Wholesale / Retail Trade [ ] Transportation [ ] Manufacturing [ ] Food Services [ ] Other Services [ ] Information Services [ ] Administrative and Support Services Describe the primary activities of your firm: 2 P age

3 Firm established on: / / I / we have owned this business since / / Number of employees: Full time: Part time: Total: Number of Native American Employees: Legal Structure [ ] Sole Proprietorship [ ] Partnership [ ] Corporation [ ] Joint Venture Do others have either controlling interest or financial interest in the firm? [ ] Yes [ ] No Percentage owned by applicant: % Federal Tax ID (if any): State ID No.: Corporation No. (if applicable): Construction Contractor s Board (CCB) License No: (attach copy) Including electrical, plumbing, landscaping, welding, engineering, etc. List other professional licenses. Certification with any state Minority Business Enterprise (MBE), Women Business Enterprise (WBE), Disadvantaged Business Enterprise (DBE), or Emerging Small Business (ESB) program. If so, please provide copy of certification approval. State(s) Certified: Small Business Administration 8(a) Certification No.: Please provide copy of certification approval. Exp: List any certifications with other TERO Tribes as an IOB: Business Structure Has your firm ever existed under different ownership, a type of ownership or a different name? [ ] Yes [ ] No If yes explain: 3 P age

4 If applicable, please list other business name(s) previously used: Does applicant s firm have any subsidiaries or affiliates or is it a subsidiary or affiliate of another concern? If yes, explain and include the name and address of subsidiary, affiliate or another concern. Describe the relationship in detail. Does the applicant/owner own or work for any other firm(s) that has a relationship with this firm (e.g. ownership interest, shared office space, financial investments, equipment, leases, personnel sharing)? [ ] Yes [ ] No If yes, identify: Name of business: Nature of business relationship: Business Status Bonding: name of surety company/agent: Bonding limit: $ Bonding capacity (Attach proof): $ Insurance coverage: name of insurance company: Name of agent: Phone no.: Amount and type of coverage: $ Has this business or owners/co-owners been debarred or suspended from contracting with any Tribes or any department or agency of the State or Federal Government? [ ] Yes [ ] No If yes, please explain and include the name of person or business, date of action, type of action, and with whom. 4 P age

5 Has your firm ever had any licenses, permits or authorizations revoked? [ ] Yes [ ] No If yes, please explain actions taken: Company References & Control List three reliable references who can verify owner s/firm s capabilities. Name Address Phone number List major projects, contracts or subcontracts performed by the firm, listing most recent first. If a new business, list previous business references. Indicate role (prime, sub, JV). Name of Project: Role: Year: Brief Description of Project: Contact Person: Phone no: Contract amount: $ Name of Project: Role: Year: Brief Description of Project: Contact Person: Phone no: Contract amount: $ 5 P age

6 Name of Project: Role: Year: Brief Description of Project: Contact Person: Phone no: Contract amount: $ Name of Project: Role: Year: Brief Description of Project: Contact Person: Phone no: Contract amount: $ Identify by name and title in company all individual owners (include non-indian owners) who have responsibilities for day-to-day management/supervision in the table below: Name Title Percent of Ownership List other businesses in which you or any other owners have ownership or interest: Identify your firm s management personnel who control your firm in the following areas: Financial Decisions Name Title Negotiating and contract execution Hiring and firing of management and operations personnel Field supervision and production Office management Purchasing of major equipment 6 P age

7 Authorized to sign company checks Authorized to make financial transactions Do any of the persons listed above own or work for any other firm(s) that have a relationship with this firm? [ ] yes [ ] No If yes identify person(s): Investments and Assets List dollar amount invested by any individual(s) to start or buy this business. Attach sources of financing and supportive documents (loan agreements, receipts, cancelled checks, initial bank statements, CDs, etc.). If other, please explain on an attached page: Name/Position Money Equipment Other-explain $ $ $ $ $ $ $ $ $ $ $ $ Do you own office equipment, field equipment, or vehicles used in the business? [ ] Yes [ ] No If yes, please include copies of equipment list, estimated value, and copies of titles of equipment and/or of promissory notes for purchase of equipment. Do you lease office equipment, field equipment, or vehicles used in the business? [ ] Yes [ ] No If yes, please include copy of lease agreement(s). Does your firm share any resources (employees/personnel, office space or facilities, equipment, storage space, financing) with any other firm or individual? [ ] Yes [ ] No If yes, please identify company and the resources shared and explain: Do you own or lease the company office space? [ ] Lease [ ] Own If yes, please include copy of lease agreement. 7 P age

8 Education, Training and Experience For the owner of a self-proprietorship, and any co-owner(s) of a partnership, joint-venture, or corporation, list for each below the education, training & experience that would qualify the owner(s) as capable of managing the business being certified: Name College/Training Year Degree/ certification Financial Statements & Taxes To qualify as a certified Native American-owned business of a least 51% ownership, the following factors determine if the firm meets the minimum requirements: VALUE: PROFITS: The Native American owner must establish that they provide real value for their stated ownership interest by providing Capital, Equipment, Real Property, or similar Assets commensurate with the value of their ownership share. The Native American owner must receive the Percentage or All Profits equal to their share of ownership interests, and make the same or greater contributions to their firm established as partnerships or joint-ventures as their non-native American partner or co-owner. The following financial information of the firm is requisite for certification: BALANCE SHEETS: Submit the most recent year-ending or quarterly balance sheet indicating the total assets, liabilities and equity of the company. INCOME STATEMENTS: Submit the most recent quarterly profit/loss statement of the company, indicating revenues/sales, expenses (including salaries and fringe paid to each owner), gross and net profit, and distribution of such profit. ANCILLARY COMPENSATION: List any management fee, bonuses, reimbursements, expenses, or other arrangements of payment distributed between the Native American and non-native American owners beyond their share of profits and salaries. 8 P age

9 TAXES: Please submit a complete copy of the owner(s) or firm s federal tax returns for the past three years if this is your initial certification with TERO. For an owner or firm already certified by TERO and is providing an annual update please submit the most recent, complete tax filing. Sole-Proprietor: Partnership: Corporation: Form 1040 (Schedule C, Profit or Loss from business). Form 1065 and all applicable schedules and attachments. Form 1120 or 1120S and all applicable schedules and attachments. Additional Information & Documentation The following information is required to complete the review of the certification application of the firm. CORPORATIONS: List all officers, directors and key employees. Provide copies of stocks issued for each shareholder [ ] Stock holder agreements, voting rights and disposal of stock, etc. [ ] Articles of Incorporation and all subsequent Amendments [ ] Copy of state incorporation certificate(s) [ ] Copy of minutes of first corporate organizational meeting and most recent meeting [ ] Most recent Annual Report [ ] Copy of Corporate By Laws [ ] Resumes of Principals of the Company [ ] Documents of interest in other businesses [ ] Organizational chart, company brochures PARTNERSHIPS: List all managers and members. [ ] Agreements of partnership (buy-outs, profit-sharing, contributions, etc.) [ ] Agreements related to stock ownership, rights, copies of shares, etc. [ ] Resumes of all partners showing education, training and employment with dates [ ] Organization chart, company brochures [ ] Proof of capital invested 9 P age

10 For all applicants, please submit the following documents, if applicable: Franchise agreements Credit agreements List of key personnel including name, title, and years of experience Bank references Certification Standards, Prescription of Preference The CTGR TERO Program has developed this standardized certification application for businesses owned by Grand Ronde Tribal members and other enrolled Native Americans. The intent of certification status is to enhance viable opportunities for experience and success in contracting and subcontracting that are under the purview of the TERO program. TERO Certified Tribally owned and Native American owned businesses will be notified of all upcoming projects by the contract-letting party and/or the TERO program for services or products provided by your business. TERO subcontracting goals are usually prescribed on all projects which require the prime contractor to exercise good faith to solicit and negotiate quotes from TEROcertified Indian-owned businesses. Please contact the TERO program for details and information. Tribal Employment Rights Program Confederated Tribes of the Grand Ronde 9615 Grand Ronde Road, Grand Ronde, OR Phone: (503) Fax: (503) P age

11 Certification Affidavit I do solemnly declare and affirm that the contents of the foregoing documents are true and correct and include all information necessary to identify and explain the operation of (name of firm), as well as the ownership thereof. The undersigned, in addition, swears that this business is at least 51 percent owned by one or more members of a federally recognized Tribe whose management and daily business operations are controlled by one or more such individuals. Any material misrepresentation will be grounds for denial or revocation of certification by the Grand Ronde Tribal Employment Rights Office Commission. Signature of owner/applicant: Name (please print/type): Title: Date: On this day of, 201 before me appeared applicant, who being duly sworn did execute the foregoing affidavit, and did state that she/he was properly authorized by (name of firm) to execute the affidavit and did so as her/his free act and deed. Notary Seal here State of: Notary Public: Commission Expires: 11 P age